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Treatment of Spinal Metastases with Epidural Cord Compression through Corpectomy and Reconstruction via the Traditional Open Approach versus the Mini-Open Approach: A Multicenter Retrospective Study

Treatment of Spinal Metastases with Epidural Cord Compression through Corpectomy and... Hindawi Journal of Oncology Volume 2019, Article ID 7904740, 11 pages https://doi.org/10.1155/2019/7904740 Research Article Treatment of Spinal Metastases with Epidural Cord Compression through Corpectomy and Reconstruction via the Traditional Open Approach versus the Mini-Open Approach: A Multicenter Retrospective Study 1 2 3,4 1 4 1 Xi Zhou, Haomin Cui, Yu He, Guixing Qiu, Dongsheng Zhou, andYongLiu Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing 100730, China Department of Orthopedic Surgery, Shanghai Jiao Tong University Alffi iated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 33 Badachu Road, Beijing 100144, China Department of Orthopaedic Surgery, Shandong Provincial Hospital Alffi iated to Shandong University, 324 Jingwu Road, Ji’nan, Shandong 250021, China Correspondence should be addressed to Yong Liu; pumchliuyong@163.com Received 7 November 2018; Accepted 22 April 2019; Published 2 May 2019 Academic Editor: Ozkan Kanat Copyright © 2019 Xi Zhou et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Patients with metastatic epidural spinal cord compression (MESCC) oen ft need surgical intervention due to pain, neurological deficits, and spinal instability. Spinal disease is commonly treated via the minimally invasive mini-open approach. However, few studies have evaluated MESCC treatment via mini-open approach. eTh present study compared the traditional open approach versus the mini-open approach for thoracolumbar MESCC. A cohort of 209 consecutive patients who were diagnosed with thoracolumbar metastases and underwent corpectomy and polymethylmethacrylate reconstruction from 2010 to 2016 was retrospectively identified. Traditional open surgery was performed in 113 patients (open group; mean age 57.7 years), while 96 patients underwent mini-open surgery (mini-open group; mean age 54.3 years). Patients were followed up for 24 months or until death. The baseline characteristics of both groups were similar. The most common origin of the primary lesion was the lung (37.3%), hematological system (22.0%), and kidney (15.8%). Surgery effective ly achieved pain relief, restored neurological function, and improved quality of life in both groups. The mini-open group was superior to the open group regarding estimated blood loss, blood transfusion, hospital stay, complications, and pain score. While the mini-open group had a longer operation time than the open group, the two groups had similar improvements in the Frankel grade and Karnofsky functional score. The 30-day mortality rate tended to be higher in the open group (5.3%) than the mini-open group (2.1%) without significance. eTh 24-month survival rate was similar in both groups (26.5% versus 26.0%). In conclusion, surgery improved pain, function, and quality of life in patients with MESCC. The mini-open approach resulted in less estimated blood loos, less blood transfusion, and shorter hospitalization than the traditional open approach, while both methods had similar mortality and morbidity rates. u Th s, the mini-open approach may be more beneficial than the traditional approach for MESCC. 1. Introduction malignant tumors [1–3]. Most studies indicate that malignant tumors most commonly originate in the lung, breast, Spinal metastasis accounts for approximately 60% of all prostate, kidney, and hematologic system [1, 4, 5]. Hematoge- osseous metastatic disease, and occult spinal disease is nous spread is responsible for over 85% of cases of metastatic present in at least 25% of patients who die as a result of epidural spinal cord compression (MESCC) with vertebral 2 Journal of Oncology collapse and compression [4]. MESCC is a devastating conse- confirmed in accordance with clinical, radiological, and quence of spinal metastases, and is an oncologic emergency pathological criteria. Surgery was performed in 226 patients. that requires rapid diagnosis and treatment. MESCC causes Of these, 17 patients did not complete follow-up. u Th s, a final marked impairments in quality of life due to pain and total of 209 patients (86 females and 123 males) with a mean neurological dysfunction [1, 4, 6]. ageof56.2years wereincludedinthepresentstudy. Multiple metastases to visceral organs and/or bones were present in eTh appropriate treatment of MESCC is a huge challenge 135 patients at the time of surgery. that requires multidisciplinary collaboration [7]. The goals of The most common symptom was pain in 176 patients MESCC treatment are to improve quality of life, maintain (84.2%), motor or sensory deficits in 124 (59.3%), and para- or improve neurological function, and relieve pain through paresis or paraplegia in 21 (10.0%). eTh preoperative Frankel spinal cord decompression, spinal stability, and local tumor grading of motor and sensory neurological deficits was grade control [1, 4, 6]. The most common therapies used to treat A (complete paraplegia) in 1.0% of patients, B (no motor MESCC are surgery, radiotherapy, or a combination of these function) in 3.8%, C (motor function present, but useless) in twomethods [1,4,5,8].Radiotherapy is eeff ctive andwidely 18.7%, D (slight motor function deficit) in 25.8%, and E (no used. However, many patients require surgery due to neu- motor deficit) in 50.7%. rological decfi its, pain, and vertebral collapse. eTh surgical indications include MSECC with relative radio-resistance, 2.2. Surgery. All patients received multidisciplinary evalua- tumor progression following radiation therapy, or spinal tion by an oncologist, chemoradiologist, protopathy expert, instability [1–6]. MESCC is surgically treated via a variety and orthopedic expert and had a satisfactory general condi- of methods and approaches. eTh ideal excision method is tion and a life expectancy of more than 3 months. Surgical en bloc resection [9]. However, the complex anatomy of the indications included MSECC with relative radio-resistance, spine makes this radical procedure extremely difficult or even tumor progression aer ft chemoradiotherapy, intractable pain impossible [9, 10]. us, Th palliative debulking methods are resistant to other methods, neurological deficits, or spinal preferred for patients with a short life expectancy, as these instability. However, posterior soft tissue invaded by tumor, methods are simpler and have lower morbidity rates [1, 4, 9, posterior cortical destruction (especially for pedicle), severe 10]. spinal deformities caused by tumor, and pedicle dysplasia The single posterior approach is considered the standard were considered as contraindications. approach to the thoracolumbar spine, and its benefits over eTh mini-open approach for transpedicular corpectomy the anterior approach include excellent exposure, direct and pedicle fixation has been described previously [11, extension from the vertebral body to the posterior elements, 13]. In brief, the skin was opened along the median line, and bilateral dura holes control [11, 12]. However, traditional while the fascia was preserved. A percutaneous pedicle open surgery involves large exposure, extensive muscular screw fixation system was applied. Aer ft fixation, the fascia and fascial dissection, and a relatively large amount of andmusclewereopenedatthelevelofthecorpectomy, bleeding; these complications may be overcome by mini- and the posterior spinal elements were exposed (Figure 1). mally invasive surgery (MIS). In MESCC, percutaneous or Transpedicular corpectomy was then performed in a rou- smallskinincisionMIS couldbeusedtoachieve adequate tine manner. eTh specific resection region depended on corpectomy and decompression difficultly; moreover, the the extent of the tumor. The discs and posterior longitu- unclear anatomic landmarks in MESCC make the operation dinal ligament were oen ft involved. A trap-door rib head even impossible. eTh mini-open approach seems to achieve a osteotomy was performed when necessary. After corpectomy, balance between lessening the surgical trauma and achieving PMMA wasusedfor thereconstructionofthe vertebral better corpectomy and decompression. However, the appli- body. cation of mini-open surgery has been concentrated on the Traditional open surgery for pedicle fixation, corpectomy, treatment of degenerative spinal disorders, and has rarely and PMMA reconstruction was performed in accordance been evaluated for MESCC. The present study compared the with routine methods. eTh fascia and muscle were opened at traditional open approach and the mini-open approach for every level of the exposed region (Figure 2). the treatment of thoracolumbar MESCC via corpectomy and Percutaneous vertebroplasty is considered an eecti ff ve polymethylmethacrylate (PMMA) reconstruction. method with which to relieve pain and stabilize the spine [1]; thus, this method was used to treat other metastatic 2. Materials and Methods vertebrae without epidural cord compression when neces- sary. Intervertebral bone grafting was rarely performed. eTh The present study was approved by the Institutional Review operative region was washed with cisplatin solution before Board of Peking Union Medical College Hospital. wound closure. Postoperative management was tailored to each indi- 2.1. Patients. We retrospectively reviewed the medical vidual patient, and comprised antibiotics, steroid admin- records of 308 patients diagnosed with MESCC between istration, and deep venous thrombosis prophylaxis. Early 2010and2016atPekingUnion MedicalCollege Hospital, activity and physiotherapy were begun as soon as possible. Shanghai Jiaotong University Affiliated Sixth People’s Progressive mobilization of sitting, ambulation, and walking Hospital, and Shandong Provincial Hospital Affiliated was performed gradually. An external orthosis was used to Shandong University. eTh diagnosis of MESCC was during the rfi st month postoperatively. Journal of Oncology 3 (a) (b) (c) (d) (e) (f) (g) Figure 1: Case example of a 52-year-old male with severe thoracic spinal stenosis and myelopathy due to myeloma involvement of T4. Illustrations showing the mini-open approach, demonstrating the little soft-tissue dissection (a). eTh thoracic magnetic resonance imaging (b- d) shows metastatic epidural spinal cord compression with tumor involvement of the T4 vertebral body. eTh patient underwent laminectomy, corpectomy, tumor resection, and polymethylmethacrylate reconstruction of T4, plus pedicle screw instrumentation of T2-T6. Postoperative anteroposterior and lateral radiography shows stable reconstruction (e-f). Pathological examination shows that the lesion was consistent with plasma cell myeloma (g). 4 Journal of Oncology (a) (b) (c) (d) (e) (f) (g) Figure 2: Case example of a 62-year-old male with metastatic lung cancer and walking difficulty. Illustrations showing the open approach, demonstrating the fascia and muscle opened at every level of the exposed region (a). Metastatic epidural spinal cord compression of T4 is seen on thoracic magnetic resonance imaging (b-d). eTh patient underwent laminectomy, corpectomy, tumor resection, and polymethylmethacrylate reconstruction of T4, plus pedicle screw instrumentation of T2-T6. Postoperative imaging shows stable reconstruction (e-f). Pathological examination shows that the lesion was consistent with adenocarcinoma of the lung (g). Journal of Oncology 5 Table 1: Patients' demographics and characteristics. Open Group Mini-open Group Patients pValue (n = 113) (n = 96) Gender 0.480 Female 49 (43.3%) 37 (38.5%) Male 64 (56.6%) 59 (61.5%) Age 57.7 54.3 0.074 BMI 22.8 21.7 0.005 ASIA grade 0.419 E 40 (35.4%) 39 (40.6%) D 46 (40.7%) 37 (38.5%) C 21 (18.6%) 16 (16.7) B 4 (3.5%) 3 (3.1%) A 2 (1.8%) 1 (1.0%) Tumor origin 0.952 Lung 41 (36.3%) 37(38.5%) Haematological 27 (23.9%) 19 (19.8%) Renal 18 (15.9%) 15 (15.6%) Liver 7 (6.2%) 9 (9.4%) Prostatic 5 (4.4%) 3 (3.1%) Breast 3 (2.7%) 5 (5.2%) Gastrointestinal 4 (3.5%) 2 (2.1%) Other 8 (7.1%) 6 (6.3%) Perioperative chemoradiotherapy 33 (29.2%) 25 (26.0%) 0.611 Extraspinal metastasis 79 (69.9%) 56 (58.3%) 0.081 BMI, Body Mass Index. 2.3. Outcomes. The operation-related outcomes included kidney (15.8%). Perioperative radiotherapy or chemotherapy operative time, estimated blood loss (EBL), transfusions of was performed in 33 (29.2%) patients in the open group, and redbloodcells(RBC) andfresh frozenplasma(FFP),hospital 25 (26.0%) in the mini-open group. eTh average hospital stays stay, and complications. The functional outcomes included in the open and mini-open groups were 21.6 days and 15.3 the visual analogue score (VAS) for pain, Frankel grade, and days, respectively. Karnofsky functional score. Patients were followed up for 2 years or until death. 3.1. Surgical Outcomes. The perioperative outcomes are shown in Table 2 and Figure 4. There was no significant 2.4. Statistical Analysis. Statistical analyses were performed dieff renceinthe numberof corpectomy andreconstruction procedures performed in each patient in the open group with SPSS software (version 19.0; SPSS Inc., Chicago, IL). Differences between groups were compared via one-way (1.9) and the mini-open group (1.8). eTh average operation analysis of variance, the Kruskal-Wallis test, and the Student’s time in the open group (225.2 min) was significantly shorter than that in the mini-open group (276.7 min; p < 0.001). t-test as appropriate. eTh Kaplan-Meier method was used to analyze the survival rate. eTh level of statistical signicfi ance The open group had a significantly greater average EBL was defined as p <0.05. (1,534.5 ml) than the mini-open group (1,007.3 ml; p < 0.001). Blood transfusion was administered to a significantly greater proportion of patients in the open group (93.8%; with a mean 3. Results of 5.2 U of RBC and 587.6 ml of FFP) compared with the mini- open group (89.6%; with a mean of 2.4 U of RBC and 327.1 ml The patient demographics and characteristics are summa- of FFP; p < 0.001). rized in Table 1 and Figure 3. The traditional open approach was used in 49 females and 64 males with a mean age of 57.7 years (open group), while the mini-open approach 3.2. Symptom Relief and Functional Outcomes. The postop- wasusedin37females and59maleswith ameanage of erative outcomes are summarized in Table 3. eTh pain was 54.3 years (mini-open group). The baseline characteristics of relieved in 92.8% of all patients. eTh VAS was improved in the two groups were similar, with no signicfi ant intergroup 103 (91.2%) patients in the open group, and 91 (94.8%) in differences in age, tumor origin, extraspinal metastasis, or the mini-open group. The average postoperative decreases ASA grade. eTh most common origin of the primary lesion in the VAS were 3.7 and 4.5 points in the open and mini- was the lung (37.3%), hematological system (22.0%), and open groups (Figure 5(a)), respectively. eTh neurological 6 Journal of Oncology Baseline Characteristics Between Open and Mini-open Groups Perioperative chemoradiotherapy (%) 70.00 Other Extraspinal metastasis (%) 60.00 Gastrointestinal Age 50.00 40.00 Breast Female Gender 30.00 (%) 20.00 Prostatic Male Tumor origin 10.00 (%) Liver BMI Renal E Haematological D ASIA grade Lung C (%) Open Group Mini-open Group Figure 3: The patient demographics and characteristics. The baseline characteristics of the open and mini-open groups were similar, with no significant intergroup differences in age, tumor origin, extraspinal m etastasis, or ASA grade. eTh mean BMI significantly differed between the two groups (p=0.005). Table 2: eTh perioperative outcomes. Open Group Mini-open Group Perioperative Outcomes pValue (n = 113) (n = 96) Number of corpectomy and reconstruction 1.9 1.8 0.800 EBL (ml) 1534.5 1007.3 <0.001 Blood transfusion Number of Patients 106 (93.8%) 86 (89.6%) 0.266 RBC (U) 5.2 2.4 <0.001 FFP (ml) 587.6 327.1 <0.001 Operation time (min) 225.2 276.7 <0.001 Length of Hospitalization (days) 21.6 15.3 0.006 Complications 0.390 Number of Patients 18 (15.9%) 9 (9.4%) 0.159 Wound infection/breakdown 5 (16.7%) 2 (18.2%) Pedicle screw misplacement 5 (16.7%) 0 (0.0%) Acute neurological aggravation 4 (13.3%) 2 (18.2%) Symptomatic local tumour recurrence 4 (13.3%) 2 (18.2%) Dural tear 3 (10.0%) 2 (18.2%) Spinal shock 2 (6.7%) 0 (0.0%) Infectious shock 2 (6.7%) 1 (9.1%) Deep vein thrombosis 2 (6.7%) 0 (0.0%) Pleural tear 1 (3.3%) 0 (0.0%) Bone cement misplacement 1 (3.3%) 0 (0.0%) Cerebral infarction 1 (3.3%) 0 (0.0%) Respiratory 0 (0.0%) 1 (9.1%) Cardiovascular 0 (0.0%) 1 (9.1%) Re-operation 9 (8.0%) 4 (4.2%) 0.390 30-day Mortality Rate 5.3% 2.1% 0.226 EBL, estimated blood loss; RBC, red blood cells; FFP, fresh frozen plasma. Journal of Oncology 7 Table 3: Symptoms relief and functional outcomes. Preoperation Postoperation Scores pValue Open Group Mini-open Group Open Group Mini-open Group VAS 6.0 6.2 2.3 1.7 <0.001 Frankel Grade E 59 (52.2%) 47 (49.0%) 75 (66.4%) 51 (53.1%) <0.001 D 21 (18.6%) 33 (34.4%) 24 (21.2%) 36 (37.5%) C 26 (23.0%) 13 (13.5%) 8 (7.1%) 7 (7.3%) B 5 (4.4%) 3 (3.1%) 3 (2.7%) 2 (2.1%) A 2 (1.8%) 0 (0.0%) 3 (2.7%) 0 (0.0%) Karnofsky Score 54.6 54 65.5 63.8 <0.001 VAS, visual analogue score. The Perioperative Outcomes Fresh Frozen Plasma (mL) Estimated Blood Loss (mL) Red Blood Cells (U) Hospital Stay (days) Operation Time (mins) Complications (%) Open Group Mini-open Group Figure 4: The perioperative outcomes. The open group had a significantly greater average estimated blood loss, blood transfusions of red blood cells and fresh frozen plasma, hospital stay, and complications than the mini-open group (p < 0.05). The average operation time in the open group was significantly shorter than that in the mini-open group (p < 0.001). deficit was fully resolved postoperatively in 108 patients. complications were wound infection/breakdown (17.1%), The Frankel grade improved postoperatively in both groups, acute neurological aggravation (14.6%), and symptomatic and improved walking ability was observed in 148 patients local tumor recurrence (14.6%). In the open group, 18 (Figure 5(b)). eTh respective Karnofsky scores in the open patients experienced 30 complications including wound and mini-open groups improved from 54.6 and 54.0 preop- infection/breakdown, pedicle screw misplacement, acute eratively to 65.5 and 63.8 postoperatively (Figure 5(c)). The neurological aggravation, and symptomatic local tumor quality of life was improved in 60.2% and 62.5% of patients recurrence. eTh mini-open group most frequently experi- in the open and mini-open groups, respectively. enced dural tear, symptomatic local tumor recurrence, and wound infection/breakdown. Thirteen patients required 3.3. Complications. Overall, postoperative complications reoperation for debridement of infection, adjustment of occurred in 27 patients (Table 2). eTh most common pedicle screw positioning, and tumor recurrence. 8 Journal of Oncology Visual Analogue Score Karnofsky Score Preoperation Postoperation Open Group Mini-open Group 8.0 6.0 4.0 2.0 0.0 2.0 4.0 Open Group Mini-open Group (a) (b) Frankel Grade Preoperation Postoperation Preoperation Postoperation Mini-open Group Open Group E B E B D A D A C C (c) Figure 5: The postoperative outcomes of the visual analogue score, Fran kel grade, and Karnofsky scores. The average postoperative decreases in the visual analogue score were 3.7 and 4.5 points in the open and mini-open groups (a). The Karnofsky scores (b) and Frankel grade (c) improved postoperatively in both groups. 3.4. Survival Rates. The 30-day mortality rate of the open group (5.3%) tended to be higher than that of the mini- open group (2.1%); however, this intergroup difference was P=0.810 not significant (p=0.226). The 24-month survival rates were similar in the open and mini-open groups (26.5% and 26.0%, respectively; p=0.810; Figure 6). 4. Discussion Bone is the third most common site for metastases (following theliver andlungs),andmostbonemetastasesarelocatedin the spine. As many as 10% of patients with spinal metastases 0 6 12 18 24 develop MESCC and experience neurological deficits, pain, Months and vertebral collapse. MIS is a suitable method that improves patient quality of life; moreover, MIS minimizes the mor- Open Group bidity and shortens the recovery time compared with open Mini-open Group surgery. The present study compared the traditional open approach versus the mini-open approach for the treatment of Figure 6: eTh 24-month survival rates. eTh 24-month survival rates thoracolumbar MESCC via corpectomy and PMMA recon- were similar in the open (26.5%) and mini-open (26.0%) groups struction. (p=0.810). Overall Survival Preoperation Postoperation Preoperation Postoperation Journal of Oncology 9 The application of MIS via the single posterior approach recovery to shorten the duration of hospitalization. Previous for the treatment of MESCC still lacks adequate evaluation; studies have reported that posterior-based corpectomy with however, a few previous studies indicate that MIS is a a large incision induces extensive stripping of the paraspinal promising prospect for MESCC treatment. One previous muscles, which is related to high morbidity and complication study that evaluated a consecutive cohort who underwent rates and extended recovery time [11, 21]. In addition, we thoracic transpedicular corpectomies for spinal metastases believe that less wound pain and better patient mobility via the mini-open approach (n=21) or the open approach resulting from the relatively lesser fascial and muscular (n=28) reported that the mini-open approach was associated dissection in the mini-open approach are also key factors in with less blood loss and shorter hospital stay compared improving postoperative recovery. with open surgery [11]. Another prospective study reported The present study found that mini-open surgery posi- goodoutcomes for10patientswithspinalmetastaseswho tively aeff cted pain relief, recovery of neurological deficits, underwent corpectomy and percutaneous instrumentation improvement of quality of life, and survival rate. Aeft r by MIS, suggesting that MIS treatment of thoracolumbar discharge from hospital, pain relief was achieved by 92.8% spinal metastases was a safe and effective palliative method of all patients, with a significantly greater decrease in the that could limit morbidity and preserve quality of life VAS in the mini-open group than in the open group. eTh [14]. Other studies have reported similar findings for MIS relatively lower postoperative VAS aeft r mini-open surgery treatment of spinal metastases, with less muscle injury, less compared with open surgery may be explained by the lesser blood loss, shorter hospital stay, and lower rates of infection woundpaincausedbythe lesser dissection ofthefasciaand compared with open surgery [15–18]. muscles. The neurological function and quality of life was In our study, patients with thoracolumbar MESCC who similarly improved postoperatively in both groups. This result underwent corpectomy and PMMA reconstruction via the is in agreeance with previous studies that reported that almost mini-open approach achieved more benefits than those who half of the patients with neurological deficits achieve recovery underwent surgery via the traditional open approach. In after surgical intervention [6]. A prospective study including particular,the mini-opengroup hadlessEBL,lessblood 118 patients with spinal metastases suggested that surgery transfusion, and shorter hospitalization than the open group. improves pain, neurological deficits, sphincteric dysfunction, Blood loss and blood transfusion are affected by many factors, and ambulatory status [6]. Approximately half of the patients including surgical techniques, tumor characteristics, and in this previous study achieved complete resolution of pain general condition. Nevertheless, compared with the mini- and neurological deficits, and the 12-month mortality rate open approach, the wider fascial and muscle exposure in the was 48%, which was similar to our results. Furthermore, the open approach is probably the reason for the greater amount Karnofsky performance status in the present study indicated of bleeding and greater requirement for intra- and post- that surgery improved the quality of life to a similar extent in operative blood transfusions. Several studies have reported both groups. that greater amounts of perioperative blood transfusion in For patients with spinal metastases, any beneficial effect patients with cancer are related to increased 30-day mortality thatmaybegainedfromnewsurgicaltechnologyshould be postoperatively and more unexpected complications [19, 20]. weighed against potential complications and morbidity. In u Th s, the relatively reduced blood transfusion requirement in the present cohort, the mini-open group had no increases mini-open surgery may achieve additional benefits. in complication and morbidity rates compared with the The operation time was significantly prolonged in the open group. eTh overall complication rate in our study mini-open group compared with the open group, which was was 12.9%, which is in accordance with previous reports probably due to the longer preparation time and increased ranging from 5 to 30% [1, 4, 6, 10]. The 24-month mortality ufl oroscopy time.However,althoughincreased operation rate was similar between the two groups, while the 30-day time may lead to more operation-related complications, the mortality rate tended to be lower in the mini-open group present study found no increase in operative risk in the mini- than the open group (but without statistical signica fi nce). eTh open group compared with the open group; the benetfi s of the greater blood loss and increased transfusion requirements mini-openapproachmayoutweightherisks associated with may be attributed to the greater 30-day mortality in the open the longer operative time. groupthaninthemini-opengroup.Moreover,themortality The hospital stay is also affected by many factors, includ- rate was largely dependent on tumor characteristics, which ing comorbidities, complications, and other unexpected rea- supports the results of other studies [2]. sons.Thepresentstudyfound that themini-open grouphad eTh present study had some limitations. eTh major short- a shorter duration of hospitalization than the open group. comings are related to the inherent nature of retrospective A shorter hospital stay may avoid hospital-related complica- studies; thus, selection bias and recall bias may affect the tions, directly represent the occurrence of less postoperative accuracy of the present findings. Furthermore, the mean BMI complications, and indirectly reflect faster recovery. In our significantly differed between the two groups, because there study, the incidence of postoperative complications in the was a tendency for surgeons to perform MIS in patients with mini-open group was 9.4%, which tended to be lower than a lower BMI, which may aeff ct the validity of the present that in the open group (15.9%), although this dieff rence results. In addition, there may have been interinstitutional did not reach statistical significance. Furthermore, the rate differences in techniques and protocols; however, there was of reoperation was higher aer ft open surgery than mini- little difference in the procedures performed by the different open surgery, which may play a role in speeding up the surgical teams. Finally, it was difficult to avoid confounder 10 Journal of Oncology biases; however, the baseline characteristics of the two groups [5] D. A. Patel and J. L. Campian, “Diagnostic and therapeutic strategies for patients with malignant epidural spinal cord were well matched. compression,” Current Treatment Options in Oncology,vol.18, no.9,p.53,2017. 5. Conclusions [6] G.M.Y.Quan,J.-M. Vital, N. Auroueretal.,“Surgeryimproves pain, function and quality of life in patients with spinal In conclusion, surgical intervention improves pain, function, metastases: a prospective study on 118 patients,” European Spine and quality of life in patients with MESCC. The application Journal,vol.20, no.11, pp.1970–1978,2011. of MIS technology has been increasing in MESCC surgery [7] E.Arana,F.M.Kovacs,A.Royuela,B.Asenjo, U. Per ´ ez- over the past decade. The mini-open approach was associated Ram´ırez, and J. Zamora, “Back pain research network task with less blood loss, less blood transfusion, and shorter force for the improvement of inter-disciplinary management hospitalization than the traditional open approach. 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Lador, “Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same Ethical Approval team,” European Spine Journal,vol.25,no.12, pp.3932–3941, This study was approved by the Institutional Review Board of Peking Union Medical College Hospital (no. S-K552). [10] K. Delank, C. Wendtner, H. T. Eich, and P. Eysel, “eTh treatment of spinal metastases,” Deutsches Aerzteblatt Online,vol.108,no. 5,pp.71–79;quiz 80,2011. Conflicts of Interest [11] D. Lau and D. Chou, “Posterior thoracic corpectomy with eTh authors declare that they have no conflicts of interest. cage reconstruction for metastatic spinal tumors: comparing the mini-open approach to the open approach,” Journal of Neurosurgery: Spine,vol.23,no.2,pp.217–227, 2015. Authors’ Contributions [12] F.H. 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Treatment of Spinal Metastases with Epidural Cord Compression through Corpectomy and Reconstruction via the Traditional Open Approach versus the Mini-Open Approach: A Multicenter Retrospective Study

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Copyright © 2019 Xi Zhou et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Oncology Volume 2019, Article ID 7904740, 11 pages https://doi.org/10.1155/2019/7904740 Research Article Treatment of Spinal Metastases with Epidural Cord Compression through Corpectomy and Reconstruction via the Traditional Open Approach versus the Mini-Open Approach: A Multicenter Retrospective Study 1 2 3,4 1 4 1 Xi Zhou, Haomin Cui, Yu He, Guixing Qiu, Dongsheng Zhou, andYongLiu Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuai Fu Yuan, Wang Fu Jing Street, Beijing 100730, China Department of Orthopedic Surgery, Shanghai Jiao Tong University Alffi iated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 33 Badachu Road, Beijing 100144, China Department of Orthopaedic Surgery, Shandong Provincial Hospital Alffi iated to Shandong University, 324 Jingwu Road, Ji’nan, Shandong 250021, China Correspondence should be addressed to Yong Liu; pumchliuyong@163.com Received 7 November 2018; Accepted 22 April 2019; Published 2 May 2019 Academic Editor: Ozkan Kanat Copyright © 2019 Xi Zhou et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Patients with metastatic epidural spinal cord compression (MESCC) oen ft need surgical intervention due to pain, neurological deficits, and spinal instability. Spinal disease is commonly treated via the minimally invasive mini-open approach. However, few studies have evaluated MESCC treatment via mini-open approach. eTh present study compared the traditional open approach versus the mini-open approach for thoracolumbar MESCC. A cohort of 209 consecutive patients who were diagnosed with thoracolumbar metastases and underwent corpectomy and polymethylmethacrylate reconstruction from 2010 to 2016 was retrospectively identified. Traditional open surgery was performed in 113 patients (open group; mean age 57.7 years), while 96 patients underwent mini-open surgery (mini-open group; mean age 54.3 years). Patients were followed up for 24 months or until death. The baseline characteristics of both groups were similar. The most common origin of the primary lesion was the lung (37.3%), hematological system (22.0%), and kidney (15.8%). Surgery effective ly achieved pain relief, restored neurological function, and improved quality of life in both groups. The mini-open group was superior to the open group regarding estimated blood loss, blood transfusion, hospital stay, complications, and pain score. While the mini-open group had a longer operation time than the open group, the two groups had similar improvements in the Frankel grade and Karnofsky functional score. The 30-day mortality rate tended to be higher in the open group (5.3%) than the mini-open group (2.1%) without significance. eTh 24-month survival rate was similar in both groups (26.5% versus 26.0%). In conclusion, surgery improved pain, function, and quality of life in patients with MESCC. The mini-open approach resulted in less estimated blood loos, less blood transfusion, and shorter hospitalization than the traditional open approach, while both methods had similar mortality and morbidity rates. u Th s, the mini-open approach may be more beneficial than the traditional approach for MESCC. 1. Introduction malignant tumors [1–3]. Most studies indicate that malignant tumors most commonly originate in the lung, breast, Spinal metastasis accounts for approximately 60% of all prostate, kidney, and hematologic system [1, 4, 5]. Hematoge- osseous metastatic disease, and occult spinal disease is nous spread is responsible for over 85% of cases of metastatic present in at least 25% of patients who die as a result of epidural spinal cord compression (MESCC) with vertebral 2 Journal of Oncology collapse and compression [4]. MESCC is a devastating conse- confirmed in accordance with clinical, radiological, and quence of spinal metastases, and is an oncologic emergency pathological criteria. Surgery was performed in 226 patients. that requires rapid diagnosis and treatment. MESCC causes Of these, 17 patients did not complete follow-up. u Th s, a final marked impairments in quality of life due to pain and total of 209 patients (86 females and 123 males) with a mean neurological dysfunction [1, 4, 6]. ageof56.2years wereincludedinthepresentstudy. Multiple metastases to visceral organs and/or bones were present in eTh appropriate treatment of MESCC is a huge challenge 135 patients at the time of surgery. that requires multidisciplinary collaboration [7]. The goals of The most common symptom was pain in 176 patients MESCC treatment are to improve quality of life, maintain (84.2%), motor or sensory deficits in 124 (59.3%), and para- or improve neurological function, and relieve pain through paresis or paraplegia in 21 (10.0%). eTh preoperative Frankel spinal cord decompression, spinal stability, and local tumor grading of motor and sensory neurological deficits was grade control [1, 4, 6]. The most common therapies used to treat A (complete paraplegia) in 1.0% of patients, B (no motor MESCC are surgery, radiotherapy, or a combination of these function) in 3.8%, C (motor function present, but useless) in twomethods [1,4,5,8].Radiotherapy is eeff ctive andwidely 18.7%, D (slight motor function deficit) in 25.8%, and E (no used. However, many patients require surgery due to neu- motor deficit) in 50.7%. rological decfi its, pain, and vertebral collapse. eTh surgical indications include MSECC with relative radio-resistance, 2.2. Surgery. All patients received multidisciplinary evalua- tumor progression following radiation therapy, or spinal tion by an oncologist, chemoradiologist, protopathy expert, instability [1–6]. MESCC is surgically treated via a variety and orthopedic expert and had a satisfactory general condi- of methods and approaches. eTh ideal excision method is tion and a life expectancy of more than 3 months. Surgical en bloc resection [9]. However, the complex anatomy of the indications included MSECC with relative radio-resistance, spine makes this radical procedure extremely difficult or even tumor progression aer ft chemoradiotherapy, intractable pain impossible [9, 10]. us, Th palliative debulking methods are resistant to other methods, neurological deficits, or spinal preferred for patients with a short life expectancy, as these instability. However, posterior soft tissue invaded by tumor, methods are simpler and have lower morbidity rates [1, 4, 9, posterior cortical destruction (especially for pedicle), severe 10]. spinal deformities caused by tumor, and pedicle dysplasia The single posterior approach is considered the standard were considered as contraindications. approach to the thoracolumbar spine, and its benefits over eTh mini-open approach for transpedicular corpectomy the anterior approach include excellent exposure, direct and pedicle fixation has been described previously [11, extension from the vertebral body to the posterior elements, 13]. In brief, the skin was opened along the median line, and bilateral dura holes control [11, 12]. However, traditional while the fascia was preserved. A percutaneous pedicle open surgery involves large exposure, extensive muscular screw fixation system was applied. Aer ft fixation, the fascia and fascial dissection, and a relatively large amount of andmusclewereopenedatthelevelofthecorpectomy, bleeding; these complications may be overcome by mini- and the posterior spinal elements were exposed (Figure 1). mally invasive surgery (MIS). In MESCC, percutaneous or Transpedicular corpectomy was then performed in a rou- smallskinincisionMIS couldbeusedtoachieve adequate tine manner. eTh specific resection region depended on corpectomy and decompression difficultly; moreover, the the extent of the tumor. The discs and posterior longitu- unclear anatomic landmarks in MESCC make the operation dinal ligament were oen ft involved. A trap-door rib head even impossible. eTh mini-open approach seems to achieve a osteotomy was performed when necessary. After corpectomy, balance between lessening the surgical trauma and achieving PMMA wasusedfor thereconstructionofthe vertebral better corpectomy and decompression. However, the appli- body. cation of mini-open surgery has been concentrated on the Traditional open surgery for pedicle fixation, corpectomy, treatment of degenerative spinal disorders, and has rarely and PMMA reconstruction was performed in accordance been evaluated for MESCC. The present study compared the with routine methods. eTh fascia and muscle were opened at traditional open approach and the mini-open approach for every level of the exposed region (Figure 2). the treatment of thoracolumbar MESCC via corpectomy and Percutaneous vertebroplasty is considered an eecti ff ve polymethylmethacrylate (PMMA) reconstruction. method with which to relieve pain and stabilize the spine [1]; thus, this method was used to treat other metastatic 2. Materials and Methods vertebrae without epidural cord compression when neces- sary. Intervertebral bone grafting was rarely performed. eTh The present study was approved by the Institutional Review operative region was washed with cisplatin solution before Board of Peking Union Medical College Hospital. wound closure. Postoperative management was tailored to each indi- 2.1. Patients. We retrospectively reviewed the medical vidual patient, and comprised antibiotics, steroid admin- records of 308 patients diagnosed with MESCC between istration, and deep venous thrombosis prophylaxis. Early 2010and2016atPekingUnion MedicalCollege Hospital, activity and physiotherapy were begun as soon as possible. Shanghai Jiaotong University Affiliated Sixth People’s Progressive mobilization of sitting, ambulation, and walking Hospital, and Shandong Provincial Hospital Affiliated was performed gradually. An external orthosis was used to Shandong University. eTh diagnosis of MESCC was during the rfi st month postoperatively. Journal of Oncology 3 (a) (b) (c) (d) (e) (f) (g) Figure 1: Case example of a 52-year-old male with severe thoracic spinal stenosis and myelopathy due to myeloma involvement of T4. Illustrations showing the mini-open approach, demonstrating the little soft-tissue dissection (a). eTh thoracic magnetic resonance imaging (b- d) shows metastatic epidural spinal cord compression with tumor involvement of the T4 vertebral body. eTh patient underwent laminectomy, corpectomy, tumor resection, and polymethylmethacrylate reconstruction of T4, plus pedicle screw instrumentation of T2-T6. Postoperative anteroposterior and lateral radiography shows stable reconstruction (e-f). Pathological examination shows that the lesion was consistent with plasma cell myeloma (g). 4 Journal of Oncology (a) (b) (c) (d) (e) (f) (g) Figure 2: Case example of a 62-year-old male with metastatic lung cancer and walking difficulty. Illustrations showing the open approach, demonstrating the fascia and muscle opened at every level of the exposed region (a). Metastatic epidural spinal cord compression of T4 is seen on thoracic magnetic resonance imaging (b-d). eTh patient underwent laminectomy, corpectomy, tumor resection, and polymethylmethacrylate reconstruction of T4, plus pedicle screw instrumentation of T2-T6. Postoperative imaging shows stable reconstruction (e-f). Pathological examination shows that the lesion was consistent with adenocarcinoma of the lung (g). Journal of Oncology 5 Table 1: Patients' demographics and characteristics. Open Group Mini-open Group Patients pValue (n = 113) (n = 96) Gender 0.480 Female 49 (43.3%) 37 (38.5%) Male 64 (56.6%) 59 (61.5%) Age 57.7 54.3 0.074 BMI 22.8 21.7 0.005 ASIA grade 0.419 E 40 (35.4%) 39 (40.6%) D 46 (40.7%) 37 (38.5%) C 21 (18.6%) 16 (16.7) B 4 (3.5%) 3 (3.1%) A 2 (1.8%) 1 (1.0%) Tumor origin 0.952 Lung 41 (36.3%) 37(38.5%) Haematological 27 (23.9%) 19 (19.8%) Renal 18 (15.9%) 15 (15.6%) Liver 7 (6.2%) 9 (9.4%) Prostatic 5 (4.4%) 3 (3.1%) Breast 3 (2.7%) 5 (5.2%) Gastrointestinal 4 (3.5%) 2 (2.1%) Other 8 (7.1%) 6 (6.3%) Perioperative chemoradiotherapy 33 (29.2%) 25 (26.0%) 0.611 Extraspinal metastasis 79 (69.9%) 56 (58.3%) 0.081 BMI, Body Mass Index. 2.3. Outcomes. The operation-related outcomes included kidney (15.8%). Perioperative radiotherapy or chemotherapy operative time, estimated blood loss (EBL), transfusions of was performed in 33 (29.2%) patients in the open group, and redbloodcells(RBC) andfresh frozenplasma(FFP),hospital 25 (26.0%) in the mini-open group. eTh average hospital stays stay, and complications. The functional outcomes included in the open and mini-open groups were 21.6 days and 15.3 the visual analogue score (VAS) for pain, Frankel grade, and days, respectively. Karnofsky functional score. Patients were followed up for 2 years or until death. 3.1. Surgical Outcomes. The perioperative outcomes are shown in Table 2 and Figure 4. There was no significant 2.4. Statistical Analysis. Statistical analyses were performed dieff renceinthe numberof corpectomy andreconstruction procedures performed in each patient in the open group with SPSS software (version 19.0; SPSS Inc., Chicago, IL). Differences between groups were compared via one-way (1.9) and the mini-open group (1.8). eTh average operation analysis of variance, the Kruskal-Wallis test, and the Student’s time in the open group (225.2 min) was significantly shorter than that in the mini-open group (276.7 min; p < 0.001). t-test as appropriate. eTh Kaplan-Meier method was used to analyze the survival rate. eTh level of statistical signicfi ance The open group had a significantly greater average EBL was defined as p <0.05. (1,534.5 ml) than the mini-open group (1,007.3 ml; p < 0.001). Blood transfusion was administered to a significantly greater proportion of patients in the open group (93.8%; with a mean 3. Results of 5.2 U of RBC and 587.6 ml of FFP) compared with the mini- open group (89.6%; with a mean of 2.4 U of RBC and 327.1 ml The patient demographics and characteristics are summa- of FFP; p < 0.001). rized in Table 1 and Figure 3. The traditional open approach was used in 49 females and 64 males with a mean age of 57.7 years (open group), while the mini-open approach 3.2. Symptom Relief and Functional Outcomes. The postop- wasusedin37females and59maleswith ameanage of erative outcomes are summarized in Table 3. eTh pain was 54.3 years (mini-open group). The baseline characteristics of relieved in 92.8% of all patients. eTh VAS was improved in the two groups were similar, with no signicfi ant intergroup 103 (91.2%) patients in the open group, and 91 (94.8%) in differences in age, tumor origin, extraspinal metastasis, or the mini-open group. The average postoperative decreases ASA grade. eTh most common origin of the primary lesion in the VAS were 3.7 and 4.5 points in the open and mini- was the lung (37.3%), hematological system (22.0%), and open groups (Figure 5(a)), respectively. eTh neurological 6 Journal of Oncology Baseline Characteristics Between Open and Mini-open Groups Perioperative chemoradiotherapy (%) 70.00 Other Extraspinal metastasis (%) 60.00 Gastrointestinal Age 50.00 40.00 Breast Female Gender 30.00 (%) 20.00 Prostatic Male Tumor origin 10.00 (%) Liver BMI Renal E Haematological D ASIA grade Lung C (%) Open Group Mini-open Group Figure 3: The patient demographics and characteristics. The baseline characteristics of the open and mini-open groups were similar, with no significant intergroup differences in age, tumor origin, extraspinal m etastasis, or ASA grade. eTh mean BMI significantly differed between the two groups (p=0.005). Table 2: eTh perioperative outcomes. Open Group Mini-open Group Perioperative Outcomes pValue (n = 113) (n = 96) Number of corpectomy and reconstruction 1.9 1.8 0.800 EBL (ml) 1534.5 1007.3 <0.001 Blood transfusion Number of Patients 106 (93.8%) 86 (89.6%) 0.266 RBC (U) 5.2 2.4 <0.001 FFP (ml) 587.6 327.1 <0.001 Operation time (min) 225.2 276.7 <0.001 Length of Hospitalization (days) 21.6 15.3 0.006 Complications 0.390 Number of Patients 18 (15.9%) 9 (9.4%) 0.159 Wound infection/breakdown 5 (16.7%) 2 (18.2%) Pedicle screw misplacement 5 (16.7%) 0 (0.0%) Acute neurological aggravation 4 (13.3%) 2 (18.2%) Symptomatic local tumour recurrence 4 (13.3%) 2 (18.2%) Dural tear 3 (10.0%) 2 (18.2%) Spinal shock 2 (6.7%) 0 (0.0%) Infectious shock 2 (6.7%) 1 (9.1%) Deep vein thrombosis 2 (6.7%) 0 (0.0%) Pleural tear 1 (3.3%) 0 (0.0%) Bone cement misplacement 1 (3.3%) 0 (0.0%) Cerebral infarction 1 (3.3%) 0 (0.0%) Respiratory 0 (0.0%) 1 (9.1%) Cardiovascular 0 (0.0%) 1 (9.1%) Re-operation 9 (8.0%) 4 (4.2%) 0.390 30-day Mortality Rate 5.3% 2.1% 0.226 EBL, estimated blood loss; RBC, red blood cells; FFP, fresh frozen plasma. Journal of Oncology 7 Table 3: Symptoms relief and functional outcomes. Preoperation Postoperation Scores pValue Open Group Mini-open Group Open Group Mini-open Group VAS 6.0 6.2 2.3 1.7 <0.001 Frankel Grade E 59 (52.2%) 47 (49.0%) 75 (66.4%) 51 (53.1%) <0.001 D 21 (18.6%) 33 (34.4%) 24 (21.2%) 36 (37.5%) C 26 (23.0%) 13 (13.5%) 8 (7.1%) 7 (7.3%) B 5 (4.4%) 3 (3.1%) 3 (2.7%) 2 (2.1%) A 2 (1.8%) 0 (0.0%) 3 (2.7%) 0 (0.0%) Karnofsky Score 54.6 54 65.5 63.8 <0.001 VAS, visual analogue score. The Perioperative Outcomes Fresh Frozen Plasma (mL) Estimated Blood Loss (mL) Red Blood Cells (U) Hospital Stay (days) Operation Time (mins) Complications (%) Open Group Mini-open Group Figure 4: The perioperative outcomes. The open group had a significantly greater average estimated blood loss, blood transfusions of red blood cells and fresh frozen plasma, hospital stay, and complications than the mini-open group (p < 0.05). The average operation time in the open group was significantly shorter than that in the mini-open group (p < 0.001). deficit was fully resolved postoperatively in 108 patients. complications were wound infection/breakdown (17.1%), The Frankel grade improved postoperatively in both groups, acute neurological aggravation (14.6%), and symptomatic and improved walking ability was observed in 148 patients local tumor recurrence (14.6%). In the open group, 18 (Figure 5(b)). eTh respective Karnofsky scores in the open patients experienced 30 complications including wound and mini-open groups improved from 54.6 and 54.0 preop- infection/breakdown, pedicle screw misplacement, acute eratively to 65.5 and 63.8 postoperatively (Figure 5(c)). The neurological aggravation, and symptomatic local tumor quality of life was improved in 60.2% and 62.5% of patients recurrence. eTh mini-open group most frequently experi- in the open and mini-open groups, respectively. enced dural tear, symptomatic local tumor recurrence, and wound infection/breakdown. Thirteen patients required 3.3. Complications. Overall, postoperative complications reoperation for debridement of infection, adjustment of occurred in 27 patients (Table 2). eTh most common pedicle screw positioning, and tumor recurrence. 8 Journal of Oncology Visual Analogue Score Karnofsky Score Preoperation Postoperation Open Group Mini-open Group 8.0 6.0 4.0 2.0 0.0 2.0 4.0 Open Group Mini-open Group (a) (b) Frankel Grade Preoperation Postoperation Preoperation Postoperation Mini-open Group Open Group E B E B D A D A C C (c) Figure 5: The postoperative outcomes of the visual analogue score, Fran kel grade, and Karnofsky scores. The average postoperative decreases in the visual analogue score were 3.7 and 4.5 points in the open and mini-open groups (a). The Karnofsky scores (b) and Frankel grade (c) improved postoperatively in both groups. 3.4. Survival Rates. The 30-day mortality rate of the open group (5.3%) tended to be higher than that of the mini- open group (2.1%); however, this intergroup difference was P=0.810 not significant (p=0.226). The 24-month survival rates were similar in the open and mini-open groups (26.5% and 26.0%, respectively; p=0.810; Figure 6). 4. Discussion Bone is the third most common site for metastases (following theliver andlungs),andmostbonemetastasesarelocatedin the spine. As many as 10% of patients with spinal metastases 0 6 12 18 24 develop MESCC and experience neurological deficits, pain, Months and vertebral collapse. MIS is a suitable method that improves patient quality of life; moreover, MIS minimizes the mor- Open Group bidity and shortens the recovery time compared with open Mini-open Group surgery. The present study compared the traditional open approach versus the mini-open approach for the treatment of Figure 6: eTh 24-month survival rates. eTh 24-month survival rates thoracolumbar MESCC via corpectomy and PMMA recon- were similar in the open (26.5%) and mini-open (26.0%) groups struction. (p=0.810). Overall Survival Preoperation Postoperation Preoperation Postoperation Journal of Oncology 9 The application of MIS via the single posterior approach recovery to shorten the duration of hospitalization. Previous for the treatment of MESCC still lacks adequate evaluation; studies have reported that posterior-based corpectomy with however, a few previous studies indicate that MIS is a a large incision induces extensive stripping of the paraspinal promising prospect for MESCC treatment. One previous muscles, which is related to high morbidity and complication study that evaluated a consecutive cohort who underwent rates and extended recovery time [11, 21]. In addition, we thoracic transpedicular corpectomies for spinal metastases believe that less wound pain and better patient mobility via the mini-open approach (n=21) or the open approach resulting from the relatively lesser fascial and muscular (n=28) reported that the mini-open approach was associated dissection in the mini-open approach are also key factors in with less blood loss and shorter hospital stay compared improving postoperative recovery. with open surgery [11]. Another prospective study reported The present study found that mini-open surgery posi- goodoutcomes for10patientswithspinalmetastaseswho tively aeff cted pain relief, recovery of neurological deficits, underwent corpectomy and percutaneous instrumentation improvement of quality of life, and survival rate. Aeft r by MIS, suggesting that MIS treatment of thoracolumbar discharge from hospital, pain relief was achieved by 92.8% spinal metastases was a safe and effective palliative method of all patients, with a significantly greater decrease in the that could limit morbidity and preserve quality of life VAS in the mini-open group than in the open group. eTh [14]. Other studies have reported similar findings for MIS relatively lower postoperative VAS aeft r mini-open surgery treatment of spinal metastases, with less muscle injury, less compared with open surgery may be explained by the lesser blood loss, shorter hospital stay, and lower rates of infection woundpaincausedbythe lesser dissection ofthefasciaand compared with open surgery [15–18]. muscles. The neurological function and quality of life was In our study, patients with thoracolumbar MESCC who similarly improved postoperatively in both groups. This result underwent corpectomy and PMMA reconstruction via the is in agreeance with previous studies that reported that almost mini-open approach achieved more benefits than those who half of the patients with neurological deficits achieve recovery underwent surgery via the traditional open approach. In after surgical intervention [6]. A prospective study including particular,the mini-opengroup hadlessEBL,lessblood 118 patients with spinal metastases suggested that surgery transfusion, and shorter hospitalization than the open group. improves pain, neurological deficits, sphincteric dysfunction, Blood loss and blood transfusion are affected by many factors, and ambulatory status [6]. Approximately half of the patients including surgical techniques, tumor characteristics, and in this previous study achieved complete resolution of pain general condition. Nevertheless, compared with the mini- and neurological deficits, and the 12-month mortality rate open approach, the wider fascial and muscle exposure in the was 48%, which was similar to our results. Furthermore, the open approach is probably the reason for the greater amount Karnofsky performance status in the present study indicated of bleeding and greater requirement for intra- and post- that surgery improved the quality of life to a similar extent in operative blood transfusions. Several studies have reported both groups. that greater amounts of perioperative blood transfusion in For patients with spinal metastases, any beneficial effect patients with cancer are related to increased 30-day mortality thatmaybegainedfromnewsurgicaltechnologyshould be postoperatively and more unexpected complications [19, 20]. weighed against potential complications and morbidity. In u Th s, the relatively reduced blood transfusion requirement in the present cohort, the mini-open group had no increases mini-open surgery may achieve additional benefits. in complication and morbidity rates compared with the The operation time was significantly prolonged in the open group. eTh overall complication rate in our study mini-open group compared with the open group, which was was 12.9%, which is in accordance with previous reports probably due to the longer preparation time and increased ranging from 5 to 30% [1, 4, 6, 10]. The 24-month mortality ufl oroscopy time.However,althoughincreased operation rate was similar between the two groups, while the 30-day time may lead to more operation-related complications, the mortality rate tended to be lower in the mini-open group present study found no increase in operative risk in the mini- than the open group (but without statistical signica fi nce). eTh open group compared with the open group; the benetfi s of the greater blood loss and increased transfusion requirements mini-openapproachmayoutweightherisks associated with may be attributed to the greater 30-day mortality in the open the longer operative time. groupthaninthemini-opengroup.Moreover,themortality The hospital stay is also affected by many factors, includ- rate was largely dependent on tumor characteristics, which ing comorbidities, complications, and other unexpected rea- supports the results of other studies [2]. sons.Thepresentstudyfound that themini-open grouphad eTh present study had some limitations. eTh major short- a shorter duration of hospitalization than the open group. comings are related to the inherent nature of retrospective A shorter hospital stay may avoid hospital-related complica- studies; thus, selection bias and recall bias may affect the tions, directly represent the occurrence of less postoperative accuracy of the present findings. Furthermore, the mean BMI complications, and indirectly reflect faster recovery. In our significantly differed between the two groups, because there study, the incidence of postoperative complications in the was a tendency for surgeons to perform MIS in patients with mini-open group was 9.4%, which tended to be lower than a lower BMI, which may aeff ct the validity of the present that in the open group (15.9%), although this dieff rence results. In addition, there may have been interinstitutional did not reach statistical significance. Furthermore, the rate differences in techniques and protocols; however, there was of reoperation was higher aer ft open surgery than mini- little difference in the procedures performed by the different open surgery, which may play a role in speeding up the surgical teams. Finally, it was difficult to avoid confounder 10 Journal of Oncology biases; however, the baseline characteristics of the two groups [5] D. A. Patel and J. L. 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